Offline: What the war against ISIL means for health

Abstract

United Nations Resolution 2249, passed on Nov 20, 2015, by the Security Council, argues that Islamic State in Iraq and the Levant (ISIL, Da'esh) “constitutes a global and unprecedented threat to international peace and security”. Is that statement fair? Despite saturation news coverage and the rhetoric of war, ISIL is not (yet) a threat to the security and wellbeing of the entire world. Its effects have been acute and severe but so far geographically localised—to the Middle East, south Asia, north Africa, and, with the recent terrorist bombings in Paris, western Europe. Still, even if one acknowledges the circumscribed danger of ISIL, it seems reasonable to say that we are now observing unprecedented levels of fanaticism-inspired violence in several countries. What the victims of this fanaticism are dealing with is not the product of “psychopathic monsters”, to use US Secretary of State John Kerry's memorable, but incorrect, phrase. Instead, it is something far more deeply ingrained in the character of the 21st century. The writer, Amos Oz, called the syndrome of our century “the clash between fanatics of all colours and the rest of us”. Certainly, several western powers now consider themselves at war. Whether one agrees with this language or not, it is plain that ISIL's actions at home and overseas will have consequences for health. What are those consequences? The negative effects of ISIL on health are all too clear. First, there will be higher rates of conflict-related mortality. According to the Global Burden of Disease, the number of deaths from war-related violence is small by comparison with many other causes. The publicity attached to those deaths will make them far more visible than has hitherto been the case. We must expect health workers to be among these casualties, despite their specially protected status. As the terrifying events that took place in the Médecins Sans Frontières hospital facility in Kunduz, Afghanistan, showed, health and humanitarian workers will not be spared attack from either enemy or ally. Second, there will be serious damage to health systems—their infrastructure, services, medical supplies, and information systems. The Sustainable Development Goal (SDG) target of universal health coverage will be badly set back for some nations by the actions of ISIL. Third, the so far neglected subject of refugee health will become increasingly important in global health. Many European nations are considering how to stem the flow of migrants crossing their borders. But the forces that are creating mass migration—for example, conflict, resource scarcity, ecosystem damage, and economic collapse—do not seem to be in abeyance. With these precipitating causes worsening, western nations should plan for more, not less, mass migration. And the refugees that are displaced and dispersed will suffer acute and chronic effects to their health, effects that will challenge already fragile health systems in some receiving countries. Furthermore, the social and mental health impacts on migrants will include stigma, fear, despair, vulnerability, and social exclusion. Fourth, ecosystems will be harmed, thereby further threatening the health of human populations. Finally, political priorities will likely shift away from traditional domestic concerns—the economy, jobs, crime, health, and education. Domestic budgets will be revised to inject cash into national security and defence. Health will be one important budgetary casualty. But there may be another way to view the current conflagration in international relations. Could it offer a series of opportunities to forge a new vision for the health and wellbeing of all peoples under threat? The UN is constructed on three pillars. The first is the conventional territory of global health—development. The SDGs have reimplanted development into the second dimension of the UN's work—human rights. But the third pillar of the UN—peace and security—has largely eclipsed thinking in health. Peace and justice are targets of SDG 16. But exactly how the global health community embraces and interprets this aspiration remains untrodden territory. Global health could make peace a central part of its vision post-2015. How might it do so? By making peace through health (and health through peace) a critical aspect and action of its work. One opening might be the new attention being given to global health security. WHO could seize first-mover advantage to kick-start this dialogue. There would be no better place to do so than the gathering of its Executive Board in January, 2016.